Journal of Case Reports: Clinical & Medical Open Access

Case Report Pneumopericardium: Rare Complication of Cocaine Abuse

Xavier Galloo1, Jan Stroobants2 and Esmael El-Abdellati2

1Department of Cardiology, ZNA Middelheim, Belgium 2Department of Emergency, ZNA Middelheim, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: Received: 08 May 2018 A 29-year old malepresented at the emergency department (ED) with chest Accepted: 07 June 2018 Published: 08 June 2018 pain and localised tenderness of the neck after snorting cocaine. Physical

Keywords: exam showed moderate on the right side of the Cocaine-related disorders; Pneumopericardium; neck. No ST-elevation compatible with cocaine-induced cardiac was Mediastinal emphysema; ; seen on ECG and blood analysis was normal (negative troponins). Chest X-ray Emergency medicine revealed subtle evidence of . Further workup with chest Copyright: © 2018 Galloo X et al., CT-scan confirmed subcutaneous emphysema with a pneumopericardium, large J Case Rep Clin Med This is an open access article distributed pneumomediastinumand a small pneumothorax. A conservative approach was under the Creative Commons Attribution License, which permits unrestricted use, pursued and the patient was kept overnight for observation. He was distribution, and reproduction in any medium, provided the original work is discharged from the ED with ambulatory follow up. A controlchest CT, properly cited. performed two weeks later, showed complete resolution of the

Citation this article: Galloo X, Stroobants pneumopericardium, - and -thorax. J, El-Abdellati E. Pneumopericardium: Rare Complication of Cocaine Abuse. J Case Pneumopericardium, –mediastinum and –thorax are rare conditions reported Rep Clin Med. 2018; 2(1):117. after cocaine abuse. A conservative approach is mandated and the outcome is

usually uncomplicated.

Introduction

Widespread cocaine abuse leads to an increase in cocaine-related Emergency

Department (ED) visits. Increasing amount of reports on respiratory and

cardiovascular effects after cocaine abuse is published. is the most

common complaint of patients with cocaine-associated ED visits [1,2]. Cocaine

activates the sympathetic nervous system leading to vasoconstriction, acute rise

in arterial blood pressure, and . Most frequent

cardiovascular complications are acute and cardiac

arrhythmias. Pneumopericardium, -mediastinum and -thorax after cocaine

abuse are rarelyreported so far and in particular pneumopericardium is

extremely rare [1,3].

Case Report

A 29-year old male (weight: 58kg, length: 178cm, BMI: 18.3 kg/m2; BMI Correspondence: Xavier Galloo, normal range: 18.5 kg/m2 – 25 kg/m2), without past medical history, Department of Cardiology, ZNA presented at the EDwith chest pain and localised tenderness of the neck. After Middelheim, Lindendreef 1, 2020 Antwerpen, Belgium, attending a social gathering he presented sudden onset of mild oppressing Tel: +32.2/280.33.05; continuous retrosternal chest pain, not irradiating, without any other symptoms Email: [email protected], [email protected] (no dyspnea or cough; no nausea or vomiting). He had not encountered any

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Pneumopericardium: Rare Complication of Cocaine Abuse. J Case Rep Clin Med. 2018; 2(1):117. Journal of Case Reports: Clinical & Medical

- trauma and reported healthy the days before. He takes excess 0,3 mmol/L, HCO3 22,2 mmol/L, saturation no medications but admits cannabis use on a weekly 98,2%, lactate 1,3 mmol/L). ECG revealed sinus basis as a teenager, but stopped doing so since he was rhythmwithout ST-elevation and normal repolarisation. 25 years old. Hereafter he only smoked marijuana on Chest X-ray showed subtle evidence of occasions (on average once a month) and hadn’t smoked pneumomediastinum and right-sided mild subcutaneous marijuana in the month prior to admission. He used emphysema in the neck (fig. 1.A. thick arrow) with air cocaine once before, approximately one year before tracking in the centre of the mediastinum (Figure 1.A. thin admission, and admitted and having snorted cocaine for arrow). There is a small denser line along the right the second time at the party the night before. He doesn’t cardiomediastinal margin (Figure 2) that is often seen in use any other drugs. As he couldn’t sleep due to the normal X-rays and attributed to an optical illusion called cocaine-related sympathetic activation and the the Mach Band effect (visual pattern due to an edge continuous chest pain, he smoked some one joint (mix of enhancement which manifests as a region of lucency tobacco and marijuana, approximately 0.32gr adjacent to convex surfaces). Although in association marijuana [4]) to ease the pain. He declared smoking with subcutaneous emphysema and air tracking in the marijuana as a normal cigarette without performing centre of the mediastinum it’s a sign compatible with prolonged inhalation or Valsalva’s manoeuvre. Apart pneumomediastinum [8]. Since subcutaneous emphysema from smoking (5 pack years) he has no other may indicate presence of pneumomediastinum further cardiovascular risk factors. Waking up around 12 am he workup with chest CT-scan was performed, which still experienced retrosternal chest pain with slight confirmed subcutaneous emphysema with a increased intensity. Additionally he noticed local pneumopericardium, large pneumomediastinum and a tenderness at the right side of the neck without muscle small pneumothorax (Figure 1B and Figure 3). A tenderness, throat pain or dyspnea. Since pain increased conservative approach was pursued and the patient was despite taking 1gram paracetamol he presented at the kept overnight for observation (continuous cardiac and ED. pulse oximetry monitoring and two-hourly blood His vital signs were within normal limits (temperature: pressure measurement as well as pain evaluation by the 36,1 °C, heart rate: 65 bpm, blood pressure: 125/75 Visual Analogue Scale) and oxygen therapy. Complete mmHg and equal both sides, respiratory rate: 13/min, pain relief was achieved by analgesics (paracetamol saturation 100% on ambient air, GCS 15/15). Physical and tramadol). As parameters remained within normal examination revealed normal respiratory auscultation range and clinical re-evaluation was reassuring with without adventitious sounds, normal cardiac sounds resolution of chest pain, he wasdischarged the next day without murmurs or clear Hamman’s sign (a crunching with expectative approach, oral analgesics and sound synchronous with the heartbeat best heard over ambulatory follow-up. ControlCT after two weeks the precordium; suggestive for pneumopericardium or - revealed complete resolution of the free intrathoracic mediastinum) [5-7] nor pulsusparadoxus. Thoracic air. examination revealed moderate subcutaneous Discussion emphysema on the right side of the neck. Further Spontaneous pneumopericardium, –mediastinum and – physical exam was unremarkable. thorax are rare conditions that have been reported Blood analysis was normal (normal haematology and after cocaine abuse but diagnostic and therapeutic biochemical analysis, no inflammation, troponins < 0,012 guidelines remain debatable. Moreover no guidelines ng/mL). Arterial blood gas on ambient air showed a for pneumopericardium are described in the current ESC respiratory alkalosis without metabolic compensation (European Society of Cardiology) guidelines for (pH 7,50, pCO2 29,3 mmHg, pO2 119,7 mmHg, base pericardial diseases [9,10]. Pneumopericardium is an

Pneumopericardium: Rare Complication of Cocaine Abuse. J Case Rep Clin Med. 2018; 2(1):117. Journal of Case Reports: Clinical & Medical extremely rare complication of cocaine abuse with so Presumable pathophysiology of pneumopericardium is a far only 9 published cases to the best of our knowledge pulmonary barotraumaversus microscopic tracheal or [11-18]. So far, the incidence of any relationship oesophageal tear due to the solid contaminants in the between the use of cocaine and spontaneous crystalline mass inhaled or snorted by the patient pneumopericardium is not known. A study with a [11,15]. Pulmonary barotrauma, also known as the systematic toxicology screening in patients presenting Macklin effect, can be explained by a three-step with spontaneous pneumopericardium/pneumothorax, process: alveolar rupture due to abrupt increase in intra- might solve this question. alveolar pressure which leads to air dissection along Pneumopericardium, -mediastinum and -thorax are bronchovascular sheaths, with eventual spreading of the defined as the presence of ‘free’ air in respectively the pulmonary interstitial emphysema into the mediastinal , the mediastinum or the pleural cavity and pericardial cavity [7,20-22]. This is the result of [7,19]. It can either be discovered without clear either sudden increase in intra-thoracic pressure due to aetiology, referred to as spontaneous or primary, or quick nasal insufflation, coughing, sneezing or vomiting, either secondary to a specific pathologic event (trauma, or either deep, forced and prolonged inhalation with infection, iatrogenic) [6]. Cocaine-related Valsalva’s manoeuver [1,3]. Our hypothesis is that the pneumopericardium, -mediastinum and –thorax are patient’s pneumopericardium, -mediastinum and –thorax considered as spontaneous or primary as determining is the result of a sudden rise in intra alveolar pressure the precise source of ‘free’ air is very difficult and its due to cocaine snorting. mechanism remains unclear.

Figure 1: Chest X-ray (A) and Chest CT (B). On both pictures subcutaneous emphysema is apparent at the right side of the neck (thick white arrow) as well as air tracking in the centre of the mediastinum indicative for mediastinal emphysema or pneumomediastinum (thin white arrow). Chest CT reveals a pneumopericardium (thin black arrow)and a small pneumothorax (thick black arrow). The pericardium can be seen between the pneumopericardium and pneumothorax (black triangle).

Pneumopericardium: Rare Complication of Cocaine Abuse. J Case Rep Clin Med. 2018; 2(1):117. Journal of Case Reports: Clinical & Medical

pneumopericardium and/or pneumomediastinum are young, thin, males without previous medical history. The most frequent complaint is chest pain, followed by neck pain, dyspnea and cough. Less frequent symptoms are odynophagia, hoarseness and feeding problems [7,9,15,17]. Emergency physicians should be alert for patients meeting these criteria as they have a considerable higher risk of developing pneumopericardium and/or pneumomediastinum. Spontaneous pneumopericardium and –mediastinum can be diagnosed on plain chest X-ray although chest CT remains the gold standard. A CT-scan is also helpful in

excluding secondary causes of pneumopericardium. Figure 2: Mach band effect versus pneumomediastinum. Zoom in on the right cardiomediastinal border showing the edge enhancement Further invasive diagnostic studies are not routinely along the cardiac margin. recommended in spontaneous pneumomediastinum and should only be performed in highly suspicious cases of oesophageal or tracheal rupture [9]. In all published cases so far, no patient was diagnosed with oesophageal rupture. Since our patient didn’t present any digestive complaints and he declined performing prolonged Valsalva’s manoeuvre we didn’t perform invasive diagnostics such as oesophagoscopy/gastroscopy or bronchoscopy. Echocardiography may be useful in evaluating unstable patients with suspicion of tamponade due to the pneumopericardium. As our patient was stable during the whole observation and didn’t present a pulsusparadoxus no echocardiography has been performed. Current guidelines for spontaneous pneumothorax and pneumomediastinum recommend a conservative Figure 3: Chest CT showing extensive subcutaneous and mediastinal approach with outpatient follow-up in selected patients emphysema compatible with large pneumomediastinum (white arrow), a pneumopericardium (thin black arrows; with pericardium marked by with minimal or no symptoms. These patients should the black triangle) and small pneumothorax (thick black arrows). receive clear advice to return in case of worsening The patient denied coughing or vomiting and didn’t dyspnea, chest pain or fever [19,23]. Treatment of perform prolonged inhalation or a Valsalva’s spontaneous pneumopericardium is not clearly identified manoeuvre. As he declared already having chest pain since the rarity of its presentation. It is considered a before smoking marijuana and having smoked benign disease, which responds well to conservative marijuana as a normal cigarette without Valsalva’s treatment, consisting of bed rest, oxygen therapy and manoeuvre; marijuana is less likely to be the cause of analgesic medications. All reported cases were treated the pneumopericardium, -mediastinum and –thorax. conservatively with complete resolution over a period of Just as the patient described in our case, most published one to two weeks. Oxygen therapy should be patients presenting with spontaneous considered as its consumption increases the diffusion

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Pneumopericardium: Rare Complication of Cocaine Abuse. J Case Rep Clin Med. 2018; 2(1):117.